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Eligibility Errors Found Under ACA

GAO investigators identify coverage and payment inaccuracies

Three reports to the House Energy and Commerce Committee and the Senate Finance Committee prepared by the Government Accountability Office (GAO) detail potentially significant discrepancies in eligibility decisions under the Affordable Care Act (ACA).

According to The New York Times, the investigators for the GAO (a nonpartisan investigative arm of Congress) said some people were receiving subsidies for private insurance at the same time they were enrolled in Medicaid. In other cases, the investigators said, the government is probably overpaying because it cannot always distinguish between newly eligible beneficiaries under the ACA and those eligible under the old rules.

The federal government is paying 100% of the cost of Medicaid for newly eligible people, but for others, it should pay a much smaller share, averaging 57% of the costs. The discrepancy is potentially significant, the investigators said, because the federal government expects to spend more than $400 billion on newly eligible Medicaid beneficiaries from 2014 to 2023.

The Obama administration, commenting on the reports, said it was intensifying its efforts to “prevent duplicate coverage” under Medicaid and government-subsidized private insurance policies sold through the marketplaces. In addition, the administration said it had provided “significant training and guidance” to make sure states correctly identified new Medicaid beneficiaries for whom the federal government should pay the entire cost.

“The Centers for Medicare and Medicaid Services [CMS] cannot identify erroneous expenditures due to incorrect eligibility determinations,” said Carolyn L. Yocom, a GAO director of health care studies. “The federal government could be paying twice — subsidizing exchange coverage and reimbursing states for Medicaid spending — for individuals enrolled in both types of coverage.”

Moreover, the auditors said, CMS, which runs the federal marketplace, “does not have procedures to automatically terminate subsidized exchange coverage when individuals are determined eligible for Medicaid.”

The GAO found that states had made incorrect decisions about Medicaid eligibility, leading to the “enrollment of individuals with incomes exceeding Medicaid standards.” In addition, it said, the federal government continued to pay subsidies for private insurance for some people after they obtained Medicaid, and states often have difficulty determining whether Medicaid beneficiaries have other sources of coverage.

The investigators also found a significant risk that people moving to insurance on the federal exchange from Medicaid would have gaps in coverage because their records were not transferred promptly from state Medicaid agencies to the exchange.